Classification of wrist instabilities

Although there are numerous classifications schemes for carpal instability, the most useful reflect
both the anatomy and pathophysiology of the condition and indicate appropriate treatment.
In categorizing carpal instability it is important to identify the direction of displacement. It may be
dorsal (DISI), volar (VISI), or be characterized by radioulnarproximodistal translation (e.g., ulnar,
radial, distal, proximal). Proximal or distal displacements, i.e., axial carpal dislocations, are rare
traumatic injuries, usually associated with a crush or blast mechanism.
Identification of the location of injury is also part of classification. Carpal instabilities can be
grouped into perilunate (perilunar), midcarpal, and proximal carpal instabilities. Perilunate
instabilities may be further divided into lesser and greater arc injuries. Lesser arc injuries involve
disruptions that follow the contour of the lunate itself, whereas greater arc injuries are
transscaphoid, capitate, hamate, or triquetral. Lesser arc injuries involve scapholunate,
lunotriquetral, and complete perilunate instabilities. Greater arc injuries are divided into scaphoid
fractures, naviculocapitate syndrome (scaphoid fracture plus perilunate dislocation), and
transscaphoid transtriquetral perilunate dislocation. Perilunate instability includes dorsal
perilunate dislocation and palmar lunate dislocation.
Mayfield's spectrum of progressive lunate instability comprises four stages. In stage I instability,
the scapholunate ligament fails leading to SL instability. In stage II, there is progression to
complete failure of the SL ligament. Stage III includes failure of the capitolunate and
triquetrolunate joints with failure of the radiotriquetral ligaments. In stage IV, there is failure of the
dorsal radioscapholunotriquetral ligament, resulting in complete palmar dislocation of the lunate.

Midcarpal instabilities
Midcarpal instabilities are classified as intrinsic (ligamentous laxity) or extrinsic in origin. They are
the most frequently recognized wrist injury, and there is greater experience with MR imaging of
these injuries. Intrinsic instabilities include palmar midcarpal instability (a VISI pattern) and dorsal
midcarpal instability (a DISI pattern). In patients with palmar midcarpal instability, patients
present with palmar subluxation at the midcarpal joint. Ulnar deviation with load on the wrist
(such as a clenched fist placing a transcarpal load) produces a painful clunk. This clunk
represents relocation of the midcarpal joint as the wrist moves into ulnar deviation. This instability
is due to a congenital or acquired laxity of the ulnar arm of the volar arcuate ligament. This is a
true transverse laxity, as all of the instability occurs between the proximal and distal rows. Dorsal
midcarpal instabilities are most commonly seen after malunion of a distal radius fracture that
leaves the distal radius articular surface in a dorsiflexed position. Dynamic midcarpal instability
centered on the lunocapitate joints has been described as a "CLIP" or capitolunate instability
pattern. There is no underlying DISI or VISI pattern of instability.

Fractures of the hamate

Fractures of the hamate, which account for approximately 2% of carpal fractures, may involve
either the body or the hook (i.e., the hamulus). Fracture of the hook of the hamate may involve
an avulsion injury of the transverse carpal ligament. Direct trauma to the volar aspect of the wrist,
the most common mechanism of injury, usually occurs in activities that require a grasping
movement, such as holding a bat, club, or racket. Chronic fracture of the hamate may be
associated with attritional rupture of the flexor tendons of the ring or little finger. Neuropathy of
the deep branch of the ulnar nerve has also been observed in these injuries.

Fractures of the hook of the hamate may cause prolonged pain and require excision. Clinical
presentation is often an ill-defined deep pain on the ulnar side of the wrist.

Dislocations of the hamate

Ligamentous injuries may result in either triquetrohamate instability or capitohamate
disassociation.

Injuries causing carpal instability of the wrist are usually caused by high impact trauma. The
pathodynamics are complex and varied, requiring in-depth study.
Interosseous cysts
An intraosseous cyst (or interosseous ganglion) of the wrist is hypointense on T1-weighted
images and hyperintense on T2- or T2*-weighted or STIR sequences. These cysts, composed of
fibrous tissue and mucoid material, are usually asymptomatic and present in a subchondral
location.